Contents

* First, what NOT
to do
*
What TO do

• A couple of
  unusual situations
• What observations
  about a seizure might be important to a physician?
• First Seizure
• Recurrent
  Seizure
• Recurrent
  Seizure -Different from Previous Ones
• Should an extra dose
  of anticonvulsant be given after a seizure?
• Does one take
  an anticonvulsant for life?
• Is there anything
  other than meds that can help prevent/control seizures?
• Sources of
  additional information
• Evaluate this
  monograph

What is a seizure? If someone
has a seizure, does that mean they suffer from epilepsy?

A seizure is a change in behavioral state which results
from abnormal electrical activity in the brain. Given the right set of
circumstances (e.g. – blow to the head, intoxication, high fever) anyone
can experience a seizure. The occurrence of a seizure in the presence of
some acute precipitating physiological disturbance does not mean that it
will ever happen after the precipitating cause has resolved. When seizures
recur without any obvious precipitant or cause, then a person may be
considered to have epilepsy.

What happens during a seizure?

"Grand Mal" –
Primary Generalized, Tonic-Clonic Seizures

The true generalized seizure is characterized by sudden
loss of consciousness, usually without warning. At onset there is usually
a general stiffening of the body, often with forceful expiration of air
(and a peculiar sound as this air passes through the throat). If the
person having the seizure is standing when this happens, there can be a
hard fall to ground or floor. This "tonic" phase of the seizure
is generally very brief but is responsible for a number of things which
often frighten witnesses. Because virtually all skeletal muscles in the
body are forcefully contracting at the same time, there may be biting of
the tongue, passage of urine, (rarely) defecation or vomiting, and
sometimes a change in color to a purplish-blue (due to muscles of
respiration being stuck in the tightened state). This phase generally
lasts about 30 seconds.

Immediately following the ‘tonic’ phase of a seizure,
convulsing begins as forceful, rhythmic jerking of arms, legs, head and
neck. This activity is variable in both its forcefulness and its duration,
but it can last a couple of minutes, building up in intensity and then
fading out while the frequency of shaking remains relatively constant.
Skin/lip/nail bed color generally returns to normal during this period.

After the convulsing ceases, there is usually a state of
deep sleepiness. During this period, all the muscles that were convulsing
are deeply relaxed. If a person in this state is in a position which makes
it hard for them to breathe, they may NOT change their own position (see
following section). The folklore about people with seizures "swallowing
their tongue" actually relates to the possible airway obstruction
which can occur in a person who is on their back with their head flexed
foward during the very sleepy period after a major convulsion.

As the sleepiness lightens, a person recovering from a
seizure may initially be confused or even hard to engage in conversation
beyond a few words. The confusion more often than not passes over minutes,
but the desire for a retreat to bed to sleep for a while sometimes lasts
for quite a while.

If a generalized convulsion is prolonged (5 minutes or
more) or if it is followed by a second seizure before complete recovery
(person is awake and interactive), it is time to seek medical assistance.

"Temporal Lobe Epilepsy"
– Complex Partial Seizures (often erroneously labeled ‘petit mal’)

The second most common form of seizure in adults is "partial"
(i.e.-the electrical ‘storm’ involves some but not all of the brain) "complex"
(i.e.- disturbance of consciousness). Usually the area of brain involved
in the seizure activity is the temporal lobe. But other parts of the brain
can give rise to seizures which fall under this heading. What most of
these seizures have in common is:

• Some form of warning or "aura" with an
  awareness that something is about to happen. This may take the form of a
  mental picture, a noxious odor, an unusual sensation in the stomach, the
  perception of a voice or music, even a particular recollection;
• Loss of awareness without collapse/unconsciousness
  (as if ‘auto-pilot’ takes over);
• Duration of minutes during which there may be
  automatisms — repetitive, non-purposeful acts — (eg.- lip smacking,
  swallowing, picking at things, garbled or semi-random speech, aimless
  walking or manipulation of objects);
• A period of confusion lasting minutes after the
  episode, possibly with sleepiness (but not the profound somnolence that
  generally follows a major convulsion). The person in this state may walk
  around, as if with purpose. Rarely, aggression may be
  manifest during this phase – especially if someone is attempting to
  passively restrain/direct movement. This aggression, when manifest, is
  not well-focused, not ‘thought-out’ and can often be avoided by leaving
  the person alone for a few minutes.

There is actually quite a bit of variety in the behavior
individuals with this type of seizure exhibit. But once a seizure of this
type has expressed itself in an individual, any subsequent episode
generally has the same aura and outward behavioral appearance as the first
one.

There is total amnesia for the period of the seizure and
variable amnesia for events just preceding and following it. Sometimes, in
some persons, this type of seizure precedes a generalized convulsion (see
above) as the electrical signal spreads out from one part of the brain to
the entire brain.

"Focal Fits" –
Simple Partial Seizures

Seizures which involve only part of the brain ("partial")
without alteration of awareness ("simple") can occur in persons
who have had injury to the brain (as from trauma, stroke, hemorrhage,
malformation, tumor). Most commonly, they involve rhythmic (2-3
cycles/second) twitching of face, hand/arm, and/or leg on the side of the
body opposite to the side of brain from which the seizure emanates.
Generally, this type of seizure lasts minutes. In some individuals, it
forms the prelude to a generalized convulsion. Occasionally, it can go on
for a very long time (hours-days). The longer it lasts, the greater the
associated fatigue. Extremely prolonged versions of this seizure type can
interfere with sleep, cause muscle pain and lead to exhaustion.

Other Seizure Types

The true "petit mal" seizure type (also known
as "Absence Attacks" or technically, "Primary Generalized
Seizures – Absence Type") is observed almost exclusively in children.
It is mentioned in this section only to assist in the campaign for
accurate terminology.

Absence seizures are characterized by abrupt and brief
interruption of consciousness without convulsion. During the typical,
seconds-long episode there is "loss of contact", "spacing
out" rarely with chewing, swallowing, or blinking automatisms.
Sometimes an individual continues doing whatever they were doing at
seizure onset, though in an automatic way. During the episode, interaction
is not possible. These episodes can be very brief, subtle and easily
missed by a nearby observer. Normally, whatever activity a child was
engaged in before the seizure is continued following it. Sometimes
children with these seizure types are misdiagnosed with learning or
behavioral problems.

There are a host of seizure types which are seen only in
children or infants.

If I see someone having a convulsion, what
can I do?

First, what NOT to do –

• DO NOT TRY TO PUT ANYTHING
  IN THE PERSONS MOUTH;
  • There is no place for the "tongue blade"
    at the bedside or in the home. In fact, it is dangerous. Many
    sticks, teeth, and other things have been broken by persons
    attempting to prevent "swallowing of the tongue". The same
    applies to fingers – never place anything in the mouth of a person
    who is actively seizing/convulsing.
  • It is sometimes appropriate to place an oral
    airway after the seizure has ended, but only if you’ve been trained
    in its use (and there happens to be one present). There is another
    way to deal with the airway during the profound sleepiness which
    sometimes follows a seizure — (read on).
• DO NOT TRY TO
  RESTRAIN THE CONVULSING LIMBS;
  • Soften the surface, remove obstacles/furnishings,
    get the person to a safe spot, cushion head with your hands, YES.
    Restrain, NO.
• IF A PERSON KNOWN TO
  HAVE ‘CONVULSIVE’ EPILEPSY SHOWS A COLOR CHANGE TOWARD BLUE IN FACE,
  LIPS, NAIL-BEDS AT THE ONSET OF A SEIZURE- COUNT TO 60;
  • The cyanosis (bluing of lips, nails, skin) that
    may accompany what in essence is a brief "respiratory arrest"
    at the beginning of a convulsion is caused by contracted and ‘stuck’
    respiratory muscles. It is not something that can be altered by any
    bystander/caregiver. It should pass relatively quickly, with
    improvement in color as the convulsion proceeds.
  • If the above state lasts beyond a minute, OR if
    it is followed by relaxation (instead of convulsive movements) with
    persistent bluish color, it would probably be wise to assume that
    this IS a respiratory arrest and NOT a seizure. [In which case the
    proper response would be Basic Life Support].
• DO NOT ATTEMPT TO GIVE THE
  PERSON MEDICATION/FLUIDS WHILE THEY ARE NON-INTERACTIVE;
  • The person should be talking before any attempt
    is made to give anything by mouth.

Now, what TO do.
(Sometimes the most important things are the simplest) –

• Especially if this is the first seizure you’ve ever
  witnessed, or if you don’t know anything about the person’s medical
  history, feel for the carotid pulse. Feeling this should provide the
  necessary reassurance that the individual is not experiencing a cardiac
  arrest. Hopefully, you can relax enough to remember the following tips –
• Create the safest possible environment for the
  seizure. Position away from objects which threaten injury. Provide a
  soft surface, if possible. Cushion head with hands to prevent banging of
  head against the ground/floor.
• As the seizure ends and a state of deep relaxation
  ensues, place the person in the "recovery position" (as
  illustrated below).
  .
  Never should the individual be left flat on their back –
  that position invites airway obstruction (by a relaxed/swollen tongue
  dropping to the back of the throat, blood from a bitten tongue, or
  vomitus). If, after positioning the person as illustrated there is any
  sign of ineffective breathing (loud snoring type sound, little/no air
  moving to/from mouth/nose), ensure that there is nothing in the mouth by
  sweeping your finger through, removing any debris as you do so [NOTE
  WELL- The seizure has stopped at this point and the person looks as if
  deeply asleep]. If there are dentures, this is the time to remove them.
  If after doing the foregoing there is still a loud snoring sound, try
  extending the neck a bit more. Other options to help open the airway
  include use of an oral airway or a performance of a
  "jaw thrust maneuver" (illustrated here).
• Recovery should proceed over minutes, though
  significant fatigue is likely. If there has not been any injury (eg.- no
  significant cuts to skin or tongue or concern regarding injurious
  effects of a fall to ground/floor), the person should be allowed to
  fulfill their desire to rest.
• Seek medical/hospital treatment if their is any
  concern about significant injury or if this is the individual’s first
  seizure.

A couple of unusual
situations–

[Author’s note: I doubt that it would be possible to
address every contingency pertaining to responses to seizure in any
document – even in the ultimate hyperlinked Web-work. Hopefully, the most
common scenarios will ultimately be well addressed in these pages.]

There are a couple of unusual circumstances that are
worth noting, especially because awareness can have a major impact upon
outcome in particularly dangerous situations.

• Seizure in water (e.g. –
  swimming). No one should swim alone. Persons known to have epilepsy of
  any type should not swim without their escort realizing that a seizure
  in water can be a particularly dangerous thing. During the forced
  expulsion of air at seizure onset, a seizing person would tend to sink
  quite rapidly. Then, with onset of the convulsive activity, water would
  tend to be drawn into the lungs. In non-convulsive seizure disorders,
  the impairment of awareness or movement control could pose some
  difficulty to a rescuer, but should not be dangerous as long as the head
  is kept above the water. Bottom-line? Consider the depth of water used
  during recreation as well as use of device which add some buoyancy.
• Concern about possible neck injury in
  fall during a seizure. Fortunately, it seems to be
  remarkably rare for serious injuries to accompany seizures. Still,
  occasionally the fall at seizure onset is a hard drop to a hard surface.
  Especially in medical settings, such an occurrence tends to reflexively
  result in taking extra precautions with respect to possible neck injury.
  This means applying traction to the head in such a way as to minimize
  flexion/extension movements, especially after the convulsion ends.
  There is still a need to move the person into the recovery position, the
  difference being that someone has to continuously hold the head in such
  a way as to keep the spine straight. This can pose a bit of difficulty
  for one attendant if the person who had the seizure is having difficulty
  breathing. This situation calls for a "jaw thrust", with the
  caveat that the neck should not be extended.
• Seizures which are prolonged or which
  occur one after another… are a special circumstance in that they
  may hurt the brain. Emergency medical attention should be sought
  immediately.

What observations about a seizure
(or what I think was a seizure) might be important to my physician?

The observations of a witness are generally key to
diagnosing the various forms of seizure and in distinguishing seizures
from episodes that can be confused with them (such as faints, various
forms of tremor, and a host of unusual causes of episodic behavioral
phenomena). While patients can often provide key information (or all the
information necessary when there is no interruption of consciousness), a
witness/observer is the only one who can provide the information which
leads to an accurate diagnosis. Specific observations have particular
relevance depending upon the whether this is a person’s first seizure, a
recurrent seizure or an episode differing from past seizures.

In general, it might be good to write down your
observations soon after the episode while memory is fresh, using the
following as a guide. [Some questions would best be directed to the person
who had the episode, others to a witness].

First Seizure

• What was the person doing immediately before the
  episode?
• Has there been any traumatic loss of consciousness in
  the recent (or remote) past? [Be able to provide details]. Has there
  been any recent illness (fever, "flu")?
• Did the person seem to have a feeling that something
  was about to happen before the episode? Was it even more specific than a
  ‘feeling’?
• As the seizure began, what did you see first? Was
  there any color change in skin, lips or nail-beds? Were there movements
  of eyes to one side? If so, which side? Did one side of the face twitch
  before the other? Did one limb start jerking before another? [In
  general, if any movements or postures were seen more on one side than
  another, it can be helpful to know which side did what.]
• In non-convulsive episodes, a description of exactly
  what the person did/said during and shortly after the episode would be
  helpful. Note the duration of the spell; between onset and resolution of
  any confusional period which follows.
• Was there passage of urine? of stool? Any vomiting?
• Was there any bleeding in the mouth?
• How long did the jerking part of the episode last?
• After the episode, what did the person do?

Recurrent Seizure

• Did this seizure look the same as prior ones?
• Was it longer or shorter than average?
• Have there been any recent medication changes or
  missed doses of medication?
• Has there been any recent change in sleep habit (eg.-
  up all night preceding the day of the seizure)?
• How much (if any) recent alcohol, caffeine,
  marijuana, or cocaine has been used? When was it last used in relation
  to the time the episode/seizure happened?
• Are there any new medications (prescription or
  non-prescription) being taken? Any herbal remedies?
• Have there been any unusually stressful events in
  life recently?
• Has there been any major change in weight since the
  last seizure? [Occasionally, a significant weight change may be
  associated with a change in blood anticonvulsant level in an individual
  who had long shown a stable blood level].

Recurrent Seizure, but
Different from Previous Seizures

In addition to answers to questions, from the above
section ("Recurrent Seizure") please consider the following:

• Exactly how was the episode different from previous
  ones? Was there a different ‘warning’ or "aura"? Did the spell
  involve a different part or side of the body? Did it start differently?
• Has there been any recent illness, new symptom of a
  possible illness? Any recent injury – especially blow to the head?

"Should an extra dose of
anticonvulsant be given as soon as possible after a seizure?"

In someone who is taking anticonvulsant/anti-epileptic
medication, a "breakthrough" seizure may be a sign of a blood
anticonvulsant level which has fallen too low. But occasionally
(uncommonly) a seizure can be a manifestation of toxicity from too much
anticonvulsant in the system. Thus, unless there have been prior
directions from a physician covering this contingency, or it is known that
a scheduled dose of medication was missed, it is probably most wise to
seek direction from your physician/neurologist before giving any extra
medication.

"I haven’t had a seizure
in years but I still take medication to prevent seizures. Am I
supposed to take this for the rest of my life?"

It is easier for a physician to provide well-grounded
advice regarding starting an anticonvulsant when a seizure disorder has
developed or when a person is at unusually high risk for having seizures.
Providing advice regarding when to discontinue medication in the absence
of seizures is much more difficult. There needs to be a reasoned weighing
of ongoing risk of seizure recurrence against factors such as medication
side-effect(s), cost of medications, potential drug interactions,
willingness to defer driving during and for a while after the withdrawal
of anticonvulsant. These are matters best discussed with your
physician/neurologist.

"Is there anything other
than medication that can be done to help prevent seizures?"

Seizure activity can be evoked from any brain given the
right combination of circumstances. The concept of a "seizure
threshold" is based upon the fact that with enough physiological or
pharmacologic ‘stress’, seizures can happen in any mammal (including
humans). Individuals differ in what constitutes "enough" of a
stress. Some of the factors which influence seizure threshold include
genetics (family history), brain trauma (especially "open"
or penetrating wounds to brain), a number of medications and drugs
(including things not often thought of as "drugs"), body
temperature, sleep deprivation and a host of metabolic variables (for
example: blood sugar, blood oxygen level, blood minerals, hormones).

There are a number of frequently-overlooked habits which
can have a bearing upon seizure risk.

• Caffeine (found in coffee, tea, over-the-counter
  ‘stay-awake’ pills and many carbonated beverages) lowers seizure
  threshold. This doesn’t mean that all persons with or at risk for
  seizures should abstain completely from anything with caffeine in it. It
  just means that moderation is probably wise here, especially if
  prevention of recurrent seizure is proving difficult.
• Alcohol makes it easier to have a seizure. It does so
  both as its level rises in the blood stream and as it later falls. It
  also tends to interact with just about every drug used to treat or
  prevent epilepsy. Because of its complex effects upon metabolism, body
  water and mineral balance, sugar metabolism and even sleep, alcohol use
  should probably be avoided in anyone who has had or is at special risk
  of seizure.
• Sleep-deprivation (as in changing from day-shift to
  night-shift work, or staying up all night to work on a term paper, etc.)
  probably does much to lower seizure threshold.
• Combinations of the above are, more likely than not,
  additive in there effects.

"What are some good
sources of additional information regarding seizures and epilepsy?"

Please
take a moment to evaluate this monograph.

For lengthier or more reflective comments, feel free to
write me at:

Northeast Rehabilitation Hospital
70 Butler Street
Salem, NH 03079

Acknowledgments:

Thanks to Carl Billian, MD, Greg Lipshutz, MD and
J. Prochilo for their critical reviews of this work and to N. Druke for
kindly helping with illustrations.